Case Study
Reason for Referral
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J.B. is bothered by loud noises
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Being compulsive and has rituals that he does everyday
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Paranoid that people are talking about him
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Takes everything seriously and gets upset easily
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Unable to attend school due to anxiety
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Becomes agitated and has meltdowns
Assessment Tools
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Wechsler Intelligence Scale for Children, 5th Edition (WISC-V)
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Personality Inventory for Youth (PIY)
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Burks Behavior Rating Scales (BBRS)
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Sentence Completion
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House-Tree-Person
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Kinetic Family Drawing
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Clinical Interview
General Observation
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J.B. was well-groomed: hair was perfectly styled he was neatly dressed
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Nails were bitten down to the quick
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J.B. became irritated with parents when they provided words of encouragement to
him
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During testing J.B. repeated statements of “gotta think, gotta think” and “I feel
dumb”
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Complained about loud noises in the building
General Observations Cont’d
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During subsequent visits J.B. was relaxed and talked about things that
interested him
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Took turns in the conversation
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During several visits he wore a baseball cap because he did not fix his hair
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When seen in home he was relaxed
Background & Psychosocial History
J.B. is 17 years old and in the 11th grade. He has difficulty socializing or going out
in public due to feeling like he does not fit in, and that people will judge him. He
continually believes that when he is out in public he can hear other people
talking about him and laughing at him.
J.B. endorses feelings of increased anxiety. He has specific rituals he has to
complete. He checks and rechecks lights. He spends extended periods of time
on his hair because it “must be perfect”. He does this even though he is not
leaving his house.
Background and Psychosocial History Cont’d
Noises bother J.B.. When his dad coughs he becomes extremely agitated by it.
He does not like for his mom to talk to his dad on the phone because he might
hear his dad cough. Loud cars on the street outside of his house make him
extremely angry.
Mom stated that when J.B. becomes stressed or angry he cries and has frantic
fits.
J.B. will wear the same clothes over and over. He wears his shoes extremely
tight to the point of bruising his feet.
J.B. is needy and clingy towards his parents. Mom reports that he wants hugs all
the time. Dad observes that the hugs are too intense and out of his comfort
zone.
Mental Health History
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Outpatient Mental Health Treatment
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Inpatient Mental Health Treatment
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J.B. has received outpatient services for the past 2 years
J.B. has not been placed inpatient.
Medications
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Venlafaxine (over a year ago)
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Clonazepam (over a year ago)
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Anxiety
Methylphenidate (several years ago)
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Antidepressant
Caused suicidal ideation
ADHD
Melatonin (about a year ago)
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Caused him to be sleepy throughout the day
Family and Social History
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Youngest child with 1 brother who is 24 years old
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Lives with biological parents and brother
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Family is close and has a good relationship
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Close relationship with grandparents
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No close friends. Has one friend that moved away and they still talk online.
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Stays home by himself or with his family. He does not leave his house unless it is someplace
he wants to go
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Spends his time listening to music, singing, and mixing vocals
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Stays up all night and sleeps most of the day
Developmental and Childhood History
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Premature- 3 weeks early
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Motor development delays
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Did not walk until 2 years old
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Received Soonerstart and had Speech Therapy
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Refused to eat, supplemented with protein drinks
Medical History
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Kidney Disease- diagnosed in 2016
Takes medication for high blood pressure
Drug History and Criminal History
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J.B. has not taken drugs or been in trouble with the law
Educational History
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J.B. went homebound after being diagnosed with kidney disease
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J.B. tried several different schools but never attended any for longer than a
few months.
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Mom reported that he would pace all night until he made himself sick so
she let him stay home from school
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Currently enrolled with an online school and doing well
Symptoms/Current Problems
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Refuses to leave his house
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Becomes anxious when plans are made, to the point he becomes sick
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Not sleeping at night
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Believes people are talking about him when he goes out in public
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Has specific rituals he must complete
Diagnostic Impression
Official Diagnosis
ICD-10
Disorder
R46.81
Obsessive Compulsive Disorder
F33.3
Major Depressive Disorder, Recurrent, Severe with
Psychotic Features
F80..82
Social/Pragmatic Communication Disorder V Mild
Autism Spectrum Disorder
F40.10
Social Phobia V Paranoid Personality Disorder,
Emergent
F70
Mild Intellectual Disability, Provisional
My Diagnosis
DSM-V
Disorder
299.00
Autism Spectrum Disorder Level 1
317
Intellectual Disability-Mild
300.23
Social Anxiety Disorder
Treatment
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CBT-Cognitive Restructuring
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Social Skills Training